Fundamentals

An Older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response? 1. "I have a legal obligation to report this type of abuse. " 2. "I promise I won't tell anyone, but let's see what we can do about this." 3. "Let's talk about ways that will prevent your daughter from hitting you. " 4. "This should not be happening. If it happens again, you must call the emergency department.

1

Nurse is caring for a client with hyperparathyroidism and notes the client serum calcium level is 13 mg/dL. Which prescribed medication should the nurse plan to assist in administering to the client? 1. Calcitonin 2. Calcium chloride 3. Calcium gluconate 4. Large doses of vitamin D.

1

Nurse reviews client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands that which condition would cause this serum calcium level? 1. Prolonged bed rest 2. Adrenal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1

The nurse is planning to reinforce nutrition instructions to an African American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice with African American heritage? 1. Raw fish 2. Red meat 3. Fried foods 4. Rice as the basis for all meals

Fried foods **this question is from the book.... very generalized statement**

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1. A client who requires a 24-hour urine collection 2. A client who requires twice-daily dressing changes 3. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures 4. A client who has been placed on a bowel management program and requires rectal suppositories and a daily enema

1

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.

1

5. The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during the data collection? 1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular

Psychosocial

The nurse is recording a nursing hands-off (end- of-shift) report for a client. Which information needs to be included? 1. As-needed medications given that shift 2. Normal vital signs that have been normal since admission 3. All of the tests and treatments the client has had since admission 4. Total number of scheduled medications that the client received on that shift

1

Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night 2. Abdominal wound addressing is dry and intact without drainage 3. The client seemed angry when awakened for vital sign measurement 4. Client appears to become anxious when it is time for respiratory treatment 5. The clients left lower medial leg wound is 3 cm in length without redness, drainage, or edema

1, 2, 5

A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply 1. Many choose not to have health insurance 2. They believe that health is a gift from God 3. The authority of women is equal to that of men 4. They remain secluded and avoid helping others 5. They use both traditional and alternative health care, such as healers, herbs and massage 6. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple without adornment

1, 2, 5, 6

The nurse is reading the PHCP progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approx. 800 mL daily." Which client is at risk for this loss? 1. Client with draining wounds 2. Client w/ urinary catheter 3. Client w/ fast respiratory rate 4. Client w/ NG tube to low suction

3

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

1

Nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client which food item is least likely to contain calcium? 1. Milk 2. Butter 3. Spinach 4. collard greens

2

Nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? 1. client w/ cirrhosis 2. client w/ ileostomy 3. client w/ heart failure 4. client w/ decreased kidney function

2

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose? 1. Providing clients with necessary stabilizing treatment. 2. A method of promoting quality care and risk management 3. Determining the effectiveness of interventions in relation to outcomes 4. The appropriate method of reporting to local, state, and federal agencies

2

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? 1. A client in skeletal traction 2. A client who is dependent on a ventilator 3. A postoperative client preparing for discharge 4. A client admitted during the previous shift with a diagnosis of gastroenteritis

2

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Labs are performed and the serum calcium level is 12 mg/dL. Based on this lab value, the nurse should take which action? 1. Document the value in the clients record 2. Inform the RN of lab value 3. Place lab result form in client's record 4. Reassure the client that lab result is normal

2

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1. A client who requires wound irrigation 2. A client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization

2

The nurse reviews a client's electroylyte results and notes a postassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushings syndrome 4. Overuse of laxatives

2

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. 1. "An event is termed a mass casualty when it overwhelms local medical capabilities." 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff. " 4. "Mass casualty events may require the collaboration of many local agencies to handle the situation." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department. "

2, 3, 5

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the Student, indicates an understanding Of a Violation of this client right? 1. Threatening to place a client in restraints 2. Performing a surgical procedure without consent 3. Taking photographs Of the Client without consent 4. Telling the client that he or she cannot leave the hospital

3

The licensed practical nurse enters a clients room and finds the client lying on the bathroom floor. The LPN call the RN, who check the client thoroughly and then assists the client back into bed. LPN completes an incident report and the nursing supervisor and provider are notified of the incident. Which is the next nursing action regarding the incident? 1. Place the incident report in the client's chart 2. Make a copy of the incident report for the provider 3. Document a complete entry in the client's record concerning the incident 4. Document in the client's record that an incident report has been completed

3

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team- based model of nursing practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients.

3

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing funeral arrangements.

4

An unconscious patient, bleeding profusely, is brought to the emergency department after a serious a accident. Surgery is required immediately to save the patient life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately without obtaining an informed consent.

4

Nurse is caring a for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional S/S should the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

4

Nurse is caring for a client who has been taking diuretics on long term basis. Which finding should the nurse expect to note as a result of this long term use? 1. Gurgling respirations 2. Increased BP 3. Decreased hematocrit level 4. Increased specific gravity of the urine

4

Nurse is reviewing the health records for assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? 1. client with sepsis 2. client w/ cirrhosis 3. client w/ kidney failure 4. client w/ diabetes mellitus

4

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? 1. Call the hospital lawyer. 2. Call the nursing supervisor. 3. Refuse to float to the pediatric unit. 4. Report to the pediatric unit and identify tasks that can be safely performed.

4

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1. A client complaining of muscle ache, headache, and malaise 2. A client who twisted their ankle when they fell inline skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

4

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? 1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgments when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task.

4

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? 1. A client scheduled for a chest x-ray 2. A client requiring daily dressing changes 3. A postoperative client preparing for discharge 4. A client receiving oxygen who is having difficulty breathing

4

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which S/S would be an indication of this electrolyte imbalance? 1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness

4

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? 1. Addison's disease 2. metabolic acidosis 3. intestinal obstruction 4. nasogastric suction

4

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor.

4

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. What should the nurse look for on the caridac monitor as a result of this lab value? 1. ST elevation 2. Peaked P waves 3. Prominent U waves 4. Narrow, peaked T waves

4

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition? 1. client w/ watery diarrhea 2. client with diabetes insipidus 3. Client with inadequate daily water intake 4. client w/ syndrome of inappropriate secretion of anti diuretic hormone

4

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? 1. Rapid weight loss 2. Flat hand and neck veins 3. A weak thready pulse 4. An increase in blood pressure

4

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications? 1. A 60 year old male client with rhinitis 2. A 24 year old male client with a lower back injury 3. A 10 year old female client with urinary tract infection 4. A 45 year old female client with a history of migraine headaches

A 10 year old female client with urinary tract infection

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1. Unwrapping the eating utensils for the client 2. Replacing the plastic utensil with metal utensils 3. Carefully transferring the food from paper plates to glass plates 4. Allowing the client to unwrap the utensils and prepare their own meal

Allowing the client to unwrap the utensils and prepare their own meal

The nurse consults with a dietitian regard the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan? 1. Rice 2. Fruits 3. Red meat 4. Fried foods

Rice **this question is from the book.... very generalized statement**

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? 1. I would try anything that I could if I had cancer. 2. No, because it will interact with the chemotherapy. 3. Tell me what you know about complementary therapies. 4. You need to ask your primary care provider about it.

Tell me what you know about complementary therapies

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary care provider? 1. Garlic 2. Valerian 3. Lavender 4. Glucosamine

Valerian

An anti hypertensive medication has been prescribed for a client with hypertension. The client tell the nurse that she would like to take an herbal substance and help lower her blood pressure. Which statement by the nurse is most important to provide to the client? 1. Herbal substances are not safe and should never be used 2. I will teach how to take your blood pressure so that it can be monitored closely 3. You will need to talk to your PCM before using an herbal substance 4. If you take an herbal substance you will need to have your blood pressure checked frequently

You will need to talk to your PCM before using an herbal substance